Although there is no specific treatment for ankylosing spondylitis, early treatment can relieve pain and reduce spinal ankylosis, inhibit the development of symptoms and prevent deformities. Later treatment is to correct the deformity and treat complications. For early stage patients, they should be instructed not to always rest in bed, but to sit with their backs as straight as possible against a chair. If necessary, the patient can stand with a straight back as appropriate. Sleep on a hard bed without pillows to avoid deformation of the spine and cervical spine. The disease, like other inflammatory diseases, should be properly rested, with appropriate activities and walks during the rest period, and never be bedridden all day. When sleeping at night, sedatives are available to promote sleep. 1. Principles of treatment: The goal of treatment for ankylosing spondylitis is to relieve pain and stiffness. One study showed that more than 85% of patients with ankylosing spondylitis still have pain and stiffness every day after 20 years of the disease, and more than 60% of patients need to take medication. Patient education is critical to successful treatment. Patients must understand that while pain and stiffness are well controlled with appropriate non-steroidal anti-inflammatory medication, regular therapeutic physical activity is the most important treatment to reduce or prevent deformity and disability. Patients must walk upright and do regular back stretches. Sleep on a hard bed and lie flat with the pillows removed, preferably on the back or with the back extended and prone, avoiding curled side lying. Advise the patient to quit smoking and to do regular deep breathing exercises to maintain normal chest expansion. Swimming is the best form of exercise for patients with ankylosing spondylitis, and wearing a snorkel and ventilator allows patients with significant neck flexion deformities to do freestyle exercises. Although regular physical exercise and an NSAID drug regimen successfully treat most patients with ankylosing spondylitis, some patients still require antirheumatic drugs for remission. Cardiac complications may require action valve replacement or pacemaker implantation. Pulmonary apical fibrosis, although not easily managed, rarely requires surgical resection. Cervical spine involvement may result in significant restriction of various neck movements, but the atlanto-occipital and atlanto-axial joints are not completely straightened and may also allow some degree of head rotation and head nodding movements. Special wide-field scopes are useful for such patients. Similarly, special polygons may increase the visual field in patients who cannot look forward due to severe hunchback walking. In the rare patient with advanced disease, surgical treatment is helpful. Total hip replacement produces good results and can partially or completely correct a patient’s disability due to severe hip pathology. Vertebral wedge osteotomy can be used in patients with severe hunchback, but at a relatively high risk of hemiplegia. Ankylosing spondylitis with ankylosing osteoporosis is very prone to fractures, even with relatively minor trauma, including trauma that the patient does not recall. The fracture line is often transverse. The cervical spine is the most susceptible to fracture, often at the level of cervical 5 to cervical 6 or cervical 6 to cervical 7, and is not easily detected by x-ray. Magnetic resonance imaging can be helpful in detecting fractures. In any patient with advanced ankylosing spondylitis, once he or she complains of neck pain or chest pain following a minor injury, it is important to rule out a fracture. Fractures may cause spinal discitis (destruction of the disc vertebrae) and pseudoarthrosis formation. The incidence of spinal discitis in patients with ankylosing spondylitis is reported to be 5% to 6%, with the most common site being thoracic 1 to lumbar 1. However, spinal discitis can develop spontaneously without trauma, and half of the patients are asymptomatic. Some patients require bed rest and local braking, rather than exercise, to aid in the formation of fibrosis and fusion. This may be one of the few instances where stent fixation is required. (1) Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs are still the mainstay of treatment for ankylosing spondylitis, both in the acute setting and in the chronic course of the disease. All NSAIDs have been shown to reduce pain (back pain, sacroiliac joint pain, pain from peripheral arthritis and occasional heel pain) and stiffness. The main problems with NSAIDs remain gastrointestinal side effects and kidney damage, and new drugs with fewer side effects need to be developed. In one study evaluating the short-term efficacy of celecoxib in ankylosing spondylitis, 246 patients with active ankylosing spondylitis were given placebo (n=76), celecoxib (n=80) 100 mg twice/d or ketoprofen (ketobuprofen) (n=90) 100 mg twice/d in a randomized, placebo-controlled study. The improvement of pain and functional status in the celecoxib and ketoprofen groups were both significantly better than the placebo group, and the celecoxib group, slightly better than the ketoprofen group. (2) Glucocorticoids: Oral corticosteroids are worthless in the long-term treatment of ankylosing spondylitis because of their side effects and their inability to stop the course of ankylosing spondylitis. Intractable tendon telangiectasia and persistent synovitis may respond well to topical corticosteroid therapy. Anterior uveitis, which can be better controlled by pupil dilation and eye spotting with hormones. Systemic hormone or immunosuppressive therapy may be required for refractory iritis. Intra-articular glucocorticoid injections are feasible for peripheral arthritis. Similarly, CT-guided intra-sacroiliac joint steroid hormone injections are technically feasible for those patients with intractable sacroiliac joint pain. In a 6-month open double-blind-placebo-controlled study in which 10 patients with definite sacroiliac joint inflammation (three of them with bilateral pain) participated, patients with ankylosing spondylitis were divided into two groups, one with intra-sacroiliac joint injection of 1.5 ml of long-acting hormone (equivalent to 62.5 mg of prednisone) and the control group with the same volume of saline as control, respectively, by physicians and patients Double-blind evaluation (using the V ankylosing spondylitis 10 cm score method) was performed. The results showed that the drug onset of action was from 1 to 15 days, with 8/13 patients taking effect within the first 3 days. After the first month of injection, 85% of patients in the drug group achieved good results, and by the sixth month, 58% of patients still maintained relief of sacroiliac joint symptoms, with a 33% decrease in pain index (p<0.05). In this trial, unipedal hopping was the most significant long-term improvement in clinical characteristics. This study demonstrated that local steroid hormone injections in the sacroiliac joint were well tolerated and efficacious. All observations were significantly improved in the treatment group compared to the control group. Similar heel pain-like tendon telangiectasia can also be treated with local steroid hormone injections. In recent years, there have been some similar reports in China, which have good efficacy for patients with ankylosing spondylitis. (3) Palliative drugs: Usually, palliative drugs are rarely used to treat ankylosing spondylitis. When NSAID therapy does not satisfactorily control the disease, when the patient tolerates NSAID poorly, or when the patient develops a serious condition such as extra-articular symptoms, the application of palliative drugs is considered. ① Salazosulfapyridine (Salazosulfapyridine) (SSZ or SASP): SSZ has been widely used worldwide for the treatment of ankylosing spondylitis since 1984, based on the rationale that patients with ankylosing spondylitis have ileal inflammation and a correlation between ankylosing spondylitis and inflammatory bowel disease (Crohn's disease and ulcerative colitis). A meta-analysis of the efficacy of applying SSZ for the treatment of ankylosing spondylitis showed that SSZ (1.0 g twice/d) improved the duration and degree of morning stiffness and low back pain and serum IgG levels better than placebo in patients with ankylosing spondylitis, and that people allergic to sulfonamides should not necessarily not take this drug. To date, only SSZ has been shown to be effective in the treatment of ankylosing spondylitis, and the drug is effective primarily in the patient's peripheral joints, but is ineffective or ineffective in spinal and tendon telangiectasia. The other therapeutic agents (penicillamine, antimalarials, and gold agents) have not been shown to benefit patients with ankylosing spondylitis. Methotrexate: A folic acid antagonist widely used in the treatment of RA, two recent open studies evaluated the efficacy of methotrexate in patients with persistent ankylosing spondylitis. A 3-year study found that 17 patients with ankylosing spondylitis responded well to methotrexate treatment, with only peripheral arthritis and iridocyclitis remaining unchanged. Importantly, imaging did not reveal a trend toward worsening of the spine and sacroiliac joints in patients with ankylosing spondylitis; another study over 1 year looked at the efficacy of methotrexate in 34 patients with ankylosing spondylitis with spinal lesions, 53% of whom showed improvement in clinical symptoms and a reduction in NSAID dose, lower ESR, and, in particular, significant improvement in peripheral arthritis symptoms but no change in spinal symptoms . A placebo-controlled trial is needed to determine the efficacy of methotrexate in ankylosing spondylitis. Pamidronate: Pamidronate is a diphosphonate that inhibits bone resorption and is commonly used to treat metabolic bone diseases (e.g., Paget's disease, metastatic bone disease, and hypercalcemia) and multiple myeloma. Recent studies have found that it also inhibits the production of cytokines such as IL-1, tumor necrosis factor-alpha and IL-6 and can suppress inflammatory responses in animal models of arthritis. In a recent open study evaluating the efficacy of the drug in refractory ankylosing spondylitis, 16 patients were divided into two dose groups: eight patients in the first group were given 30 mg of pamidronate intravenously once a month for 3 months, followed by 60 mg intravenously once a month for the next 3 months; eight patients in the second group were given only 60 mg intravenously once a month for 3 months. Finally, the drug was evaluated on the clinical indicators BASDAI, BASFI and laboratory inflammatory indicators (ESR) such as disease activity and patient function. In group 1, there was a significant improvement in all of these indicators. In group 2, only BASMI, a quantitative assessment of hip and spine mobility, showed some improvement. Blood sedimentation decreased progressively in group 1, with the most significant decrease by the end of the assessment point at month 6. Thus, this study suggests that pamidronate has an anti-inflammatory effect and may improve spinal symptoms in active ankylosing spondylitis, but it was an uncontrolled study. The aforementioned investigators then used a double-blind controlled trial to compare the difference between another 38 patients with ankylosing spondylitis given 60 mg of pamidronate per month and 10 mg (which was equivalent to placebo) for 6 months. The results showed a substantial improvement in clinical and functional indices in the 60 mg dose group, while their inflammatory indices (ESR, CRP) did not change significantly. The results of this study confirm previous findings that pamidronate can benefit patients with active ankylosing spondylitis. ④Anti-tumor necrosis factor-α monoclonal antibody: Tumor necrosis factor-α has a role in mediating inflammation and immunomodulation in the immune response, with effects including activation of lymphocytes, release of other cytokines (e.g. IL-1, IL-6), prostaglandins and metalloproteinases; it also promotes angiogenesis and modulates the role of adhesion molecules. In sacroiliac joint biopsies from patients with ankylosing spondylitis, large amounts of tumor necrosis factor-α mRNA expression were found indicating the involvement of tumor necrosis factor-α in the pathogenesis of ankylosing spondylitis. Serum levels of tumor necrosis factor-α were higher in patients with ankylosing spondylitis than in patients with non-inflammatory lower back pain. In addition, patients with ankylosing spondylitis and spondyloarthropathies have subclinical intestinal inflammatory lesions similar to those of Crohn's disease, for which anti-tumor necrosis factor-α therapy is effective. Therefore, anti-TNF-α therapy is also effective in ankylosing spondylitis. Anti-TNF-α drugs that have been used to treat ankylosing spondylitis include monoclonal antibodies (infliximab). It is a chimeric neutralizing monoclonal antibody on the human/mouse IgG1κ isotype chain. Two open pilot studies evaluated the efficacy of the drug in ankylosing spondylitis. The first trial verified the efficacy of the drug in 11 patients with refractory ankylosing spondylitis with severe disease activity. Patients were treated with infliximab at 4 mg/kg by intravenous infusion at weeks 0, 2, and 6. The results showed significant improvements in disease activity, functional and pain scores (BASDAI, BASFI, BASMI), and quality of life in participating patients. Serum inflammatory markers (ESR, CRP and IL-6 levels) were significantly reduced. The study also used magnetic resonance imaging (MRl) to understand spinal inflammation. At patient enrollment, three of the five patients had spinal inflammatory activity, and dynamic MRI of the spine revealed reduced or no change in inflammation within 6 weeks after three injections. 21 patients with spondyloarthropathy participated in another trial, including 10 with ankylosing spondylitis, 9 with psoriatic arthritis, and 2 with unclassified spondyloarthropathy, each using the same treatment, observation, and treatment protocol as the first trial. The same treatment and observation protocols were used as in the first trial. In the end, all patients showed improvement in spinal and peripheral joint symptoms. Inflammatory markers in the serum also decreased significantly. Improvement in symptoms was observed 3 days after the first injection and continued for 3 months. The treatment was well tolerated with no serious side effects (dizziness, headache, fatigue, diarrhea and palpitations were observed only in isolated cases). Both trials clearly support that anti-tumor necrosis factor-alpha is very effective in treating ankylosing spondylitis. However, both trials only evaluated the short-term efficacy (3-month period) of anti-TNF-α treatment without a control group and without randomization, and large, double-blind controlled trials with long-term follow-up are still needed. ⑤ Thalidomide (thalidomide): Thalidomide has specific immunomodulatory effects. It inhibits the production of tumor necrosis factor-α by monocytes and also synergistically stimulates human T lymphocytes, helper T cell response, and inhibits angiogenesis and adhesion molecule activity. In vitro tests have shown that it inhibits IL-12 production by lipopolysaccharide-stimulated monocytes, so its immunomodulatory effects can make it useful not only for the treatment of a variety of diseases, such as infectious diseases (leprosy and HIV disease) and malignant diseases (multiple myeloma), but also for the treatment of inflammatory and autoimmune diseases (inflammatory bowel disease and RA). Tumor necrosis factor-alpha plays an important role in the pathogenesis of infectious and autoimmune diseases, and therefore the mechanism of treatment of these diseases is mainly related to its inhibition of tumor necrosis factor-alpha production. The efficacy of thalidomide (Response Stop) in ankylosing spondylitis was demonstrated in 2 patients with severe and intractable ankylosing spondylitis with both spinal and peripheral joint disease, who showed a significant improvement in clinical symptoms and a decrease in inflammatory parameters (ESR and CRP levels) parallel to the symptoms. Due to the development of leukopenia, the thalidomide dose was reduced from 300 mg/d to 200 mg/d. Domestic observations showed that 200 mg/d thalidomide was effective in 19/24 patients with refractory ankylosing spondylitis, mainly by modulating the expression of inflammatory factor genes such as tumor necrosis factor-α, IL-1β, IL-6, and MIP. The main side effects include sleepiness, bitterness in the mouth, increased dandruff and dry mouth. Peripheral neuropathy and leukopenia have not been detected. Thalidomide is of concern because of its teratogenicity and women of childbearing potential need to use strict contraceptive measures. (6) Amitriptyline: Amitriptyline is a tricyclic antidepressant with 5-hydroxytryptamine and anticholinesterase activity and has mainly sedative, analgesic and hypnotic effects. Some studies have demonstrated that small doses of amitriptyline can be used to treat fibromyalgia and fatigue. The drug itself does not have anti-inflammatory effects, but is the best adjunct to low-dose NSAID therapy. Studies have found that fatigue is a major symptom in most patients with ankylosing spondylitis, and that severe fatigue leads to decreased mobility, a sense of morning stiffness and increased pain with significant sleep disturbances in patients with ankylosing spondylitis. A recent study looked at the efficacy of low-dose amitriptyline (30 mg/night) in 100 patients with ankylosing spondylitis. It was found that all assessment parameters were significantly improved in the amitriptyline group compared to the placebo group, where only pain, morning stiffness and BASFI improved. The number of patients with improved sleep was much higher in the amitriptyline group than in the placebo group (66% and 20%, respectively; p<0.001). The results demonstrated that low doses of amitriptyline were well tolerated and significantly improved sleep. Although amitriptyline improved the quality of sleep in patients with ankylosing spondylitis, morning stiffness was not worsened and, in fact, patients experienced a significant improvement in joint stiffness. Thus, the greatest advantage of amitriptyline, for the treatment of ankylosing spondylitis, is that it promotes the integrity of sleep and the resulting reduction in fatigue. 3, radiation therapy: radiation therapy because of the side effects, easy to cause white blood cell decline and radiation sickness, so it is less commonly used, but the application of small doses of multiple irradiation, to relieve symptoms and delay the onset of deformity does have some effect. 4, the treatment of complications: ① eye treatment: in order to prevent the development of iritis to glaucoma and blindness, can be local or systemic application of atropine and glucocorticoid therapy. ② Cardiac treatment: Treatment of aortic valve closure insufficiency, congestive heart failure, heart enlargement, and heart block is the same as that for other causes of the above cardiac abnormalities. When there is an indication for surgery. Surgical treatment can be considered. ③Treatment of pulmonary complications: When complicated by bacterial or mycobacterial infections, effective antibiotics or anti-mycobacterial preparations can be applied. ④Other: When the cervical spine deformity compresses the nerve, the bone plate can be surgically removed to release the compression symptoms. Second, the prognosis The evolution of the course of ankylosing spondylitis varies greatly and is characterized by alternating spontaneous remission and exacerbation, generally with a good prognosis and self-limiting. A small number of patients suffer rapid bone loss and develop severe disability early on, with hip involvement and complete ankylosis of the cervical spine. Survival of patients with mild forms is not different from the general population. However, concomitant spinal fractures, cardiovascular involvement, renal amyloidosis, and other serious complications can shorten survival in some patients. Loss of function occurs in most patients within the first 10 years of disease onset and is associated with peripheral arthritis, radiographic changes in the spine, and a "bamboo spine". In patients with a disease duration greater than 20 years, 80% of patients still have pain and stiffness, and more than 60% of patients require drug therapy. About 85% of patients have a good prognosis, even if severe deformity or disability occurs, they can still take care of themselves with surgical treatment. A small number of patients may die from heart failure, uremia and cervical fractures complicated by paraplegia.